The recent terrorist disasters left many people suddenly
bereaved of spouses, children, parents, close friends, and
coworkers. In the immediate aftermath, some have been numb or
unable to accept the loss. Many have felt shocked, lost, anxious,
depressed, and physically unwell as a result of this loss. For
many, the pain has been intense and unrelenting. In the acute
aftermath of the violent death of a loved one, a sense of
disbelief or intense, uncontrollable emotionality is very
frequent. Distressing physical symptoms are also common
(Lindeman, 1944; Stroebe & Stroebe, 1993). These emotional
and bodily reactions may be very strong and can themselves be
traumatizing, especially if they are unfamiliar and unexpected.
Such a secondary reaction can further amplify the pain caused by
the loss and can be mitigated by information about grief and
stress reactions. It is important to realize that intense and
unfamiliar emotionality is entirely normal and does not
necessarily have implications for long-term emotional stability
or health. The fact that a popular Internet book site lists 2,776
titles on the topic attests to the fact that grief is both common
and difficult. In ordinary, peaceful times millions of people die
every year, each leaving friends and family bereaved. Many
experience numbness or intense pain in the immediate aftermath.
For most, this initial reaction subsides with time, and the
bereaved person finds a way to again engage fully in life.
However, studies show bereaved individuals, in general, are at
risk for longer term mental and physical health problems. It is a
good idea to provide ongoing support, monitor the outcome of
grief, and know that professional intervention can be
helpful.
Given the universality of bereavement, there has been
relatively little research to characterize its course, develop a
nosology for bereavement problems, identify risk factors, or
guide treatment. The information provided below draws upon what
has been done and upon ongoing work.
The course of bereavement
The course of bereavement has become increasingly better
understood since the mid '80s, with the development of
several measures that have proven consistent across some
populations. These include the Texas Revised Inventory of Grief
(Faschinbauer, Zisook & DeVaul, 1987), Core Bereavement Items
(Burnett, Middleton, Raphael & Martinek, 1997), Criteria for
Complicated Grief Disorder (Horowitz, Siegel, Holen, et al.,
1997), and the Inventory of Complicated Grief (Prigerson et al.,
1995). Few studies have targeted a full range of ages and
circumstances of death and the bereaved. Most of the information
available refers to older people or widows, although selected
studies have targeted parents of deceased children, surviving
friends and partners of HIV sufferers, parents of children who
have died violently, and combat veterans. However, younger
individuals, especially men, may be at highest risk for
complications, relative to a comparison group of same age and sex
(Ball, 1977; Stroebe & Stroebe, 1983).
Research by Stroebe and colleagues (1993) provides a model of
the type of study needed. These researchers compared widows and
widowers under retirement age to a control group consisting of
married couples, interviewing participants 4 to 7 months
following their loss and again at 14 months and at two years. The
researchers found that widows who participated were more
depressed than widows who did not while the reverse was true for
widowers. It is important to keep in mind that most studies of
bereavement have succeeded in recruiting only about one-third of
eligible individuals, so all data need to be viewed in light of
the characteristics of the individuals who choose to participate.
Given this caveat, studies consistently find bereaved individuals
to have higher levels of depressive symptoms than matched
controls in the 6-12 months after the death. Most of those with
milder levels of depression improve by year 2, while those who
are clinically depressed (about 20%) remain depressed. Somatic
symptoms are reported by widows and widowers at a rate nearly 10
times the rate reported by members of the control group in the
initial 6 months, and these symptoms are still reported 4 times
as much at two years.
Less is known about the course of bereavement following
violent death, but available studies have consistently found that
symptoms and impairment are more prolonged and a sense of
resolution less likely (e.g., Murphy, 2000). A recent study of
women college students (Green, 2001) found those who experienced
a violent loss had symptoms and impairments similar to those who
experienced assault. A dissertation study by Pivar documented
grief symptoms in 70% of veterans and found that these could be
differentiated from symptoms of PTSD and depression. Taken
together, this work suggests that sudden violent bereavement is a
very intense stressor. While many people will find a way to cope
without intervention, skilled professional assistance may be
important in decreasing the morbidity and even mortality of those
bereaved as a result of disaster. In order to provide such
assistance, professionals need to be informed about grief and
about treatment strategies that have been developed and
tested.
The experience of grief
Grief is the process by which we adjust to the loss of a close
relationship. Therefore, grief is an inevitable companion
to love and attachment. The lives of those we love are interwoven
with our own in thousands of small and large ways. One's
immediate family, in particular, contributes to a sense of
comfort, security, and happiness and reinforces behavior.
Endocrine function can become entrained by cues from another
person. When this happens, losing that person requires a period
of physiological adjustment. In all cases, loss of a loved one
engenders feelings of loneliness, sadness, and vulnerability. The
death of someone close also makes one's own death
imaginable, thus evoking fear of dying. When a person experiences
the death of someone close, that person is confronted by
mortality and undergoes a certain degree of acute separation
distress. Sometimes, there is also guilt about being alive
when the other person has died, or there is guilt about not being
able to save the person or make his or her life or dying
easier.
While grief is not the same for every person, there are
certain commonalities. During the initial phase, the bereaved
person is preoccupied with the deceased, preoccupied with
feelings of yearning and longing, and with searching for him or
her. While grieving, most people withdraw from the world and turn
inward, often reviewing the course of the relationship, including
positive and negative thoughts and feelings. People often also
review the meaning the relationship had in their lives. Grief
entails a host of painful emotions that can sometimes be very
strong and persistent. Strong feelings of sadness and loneliness
almost always occur following the death of a close friend or
family member. Fear and anxiety are also common. Difficult
feelings of resentment, anger, and guilt can occur. Experiencing
any or all of these emotions following the loss of a friend or
family member is perfectly normal.
As the transition to life without a friend or family member
progresses, the intensity of grief subsides. The bereaved person
accepts the death and begins to take some comfort in positive
memories, establishing a permanent sense of connection to the
person who died. It becomes possible to reengage in activities
and relationships while still having memories of and maintaining
a sense of closeness to the deceased. The period over which this
adjustment occurs is variable, depending on the circumstances of
the death, the characteristics of the bereaved, and the nature of
the relationship. In some circumstances, intense grief persists
for many months or even years. Intrusive images and disturbing
ideas inhibit the healing process, and there is a sense that the
death is unacceptable and unfair. For some who have difficulty
coping with the death, grief sometimes seems to be all that is
left of the relationship. Also, a decrease in the intensity of
the grief may feel like a betrayal of the person who died. Some
people also have persistent feelings of guilt. When a death is
sudden, violent, and untimely, the bereaved will most likely also
face other difficulties. The condition in which unmanageably
intense and/or persistent grief symptoms occur is called
Traumatic Grief. Symptoms of Traumatic Grief are listed in Table
1. Work is underway to establish diagnostic criteria and to
develop treatments for this condition. Traumatic Grief may
predispose to other psychiatric, medical, and behavioral problems
that can complicate bereavement. These are generally treatable
conditions and need to be recognized by professionals and by the
bereaved individuals themselves.
Complications of bereavement
Bereavement is a risk factor for a range of mental and
physical health problems. Among these are the following:
Prolonged grief or Traumatic Grief
Onset or recurrence of Major Depressive Disorder
Onset or recurrence of Panic Disorder or other anxiety
disorders
Possible increased vulnerability to PTSD
Alcohol and other substance abuse
Smoking, poor nutrition, low levels of exercise
Suicidal ideation
Onset or worsening of health problems, especially
cardiovascular and immunologic dysfunction
Traumatic Grief
Grief will inevitably disrupt mental functioning following the
death of a loved one. While it should be emphasized that grief
itself is a normal process of adapting emotionally and
cognitively to the loss or absence of a loved one, sometimes the
intensity of a person's grief may be overwhelming or last
longer than is healthy. This may occur for a variety of reasons.
The relationship between the deceased and the bereaved might have
been very close or complicated; the circumstances of the death
may be sudden or traumatic, as in accident, disaster, or illness;
or the grieving person may not have good coping skills or the
social support that would help the grieving process. In
situations like these, it may be helpful to seek professional
help or counseling in order to resolve the grief.
When grief goes on longer than is healthy or when it is
overwhelming, a diagnosis of Traumatic Grief might be
appropriate. It may be helpful to draw an analogy to a physical
illness. An illness is not a characteristic of a person; it is a
state a person is in at a given time. Many illnesses are very
treatable. Another analogy is to an acute injury. People are more
or less vulnerable to disability from an injury, but some types
of injury are so severe that they always cause impairment. Using
such an analogy, it is possible to see that following an accident
or disaster or the sudden death of a very close person, it is
entirely normal to experience Traumatic Grief, just as it is
quite normal to develop tuberculosis upon exposure to a virulent
organism, and it is normal to be unable to walk on a broken leg.
It is also clear that it is a good idea to diagnose and treat
these conditions. No one would tell a person with pneumonia "pull
yourself together" or "get on with it" or expect a person with a
deep cut or a broken bone to heal him- or herself. Although
labels can be hurtful if misused, they can also be helpful. An
ill person needs to have a "sick role" and to receive treatment.
An ill person benefits from support and assistance from family
and friends, as well as from treatment by a trained
professional.
Table 1: Symptoms of Traumatic Grief (Prigerson, 1995)
Preoccupation with the deceased
Pain in the same area as the deceased
Memories are upsetting
Avoid reminders of the death
Death is unacceptable
Feeling life is empty
Longing for the person
Hear the voice of the person who died
Drawn to places and things associated with the deceased
See the person who died
Anger about the death
Feel it is unfair to live when this person died
Disbelief about the death
Bitter about the death
Feeling stunned or dazed
Envious of others
Difficulty trusting others
Lonely most of the time
Difficulty caring about others
Risk factors for complications of bereavement
Risk factors are those aspects of a situation that tend to
increase vulnerability to complications and that may slow
recovery. Existing studies suggest that risk factors relate to
the characteristics of an individual, the nature of the
relationship to the deceased, the circumstances of the death, and
the social context within which recovery takes place. Some risk
factors relate to the larger situation in which the bereaved
finds him- or herself, and some risk factors relate to the
bereaved individual's specific history and makeup. While
both kinds of risk factors raise the distress level of the
bereaved person, it is useful for clinicians to be particularly
aware of the bereaved's individual situation.
The following risk factors have been identified:
Demographic factors
Socioeconomic status
Lower
socioeconomic status is related to a poorer health status in
general. Bereavement appears to affect people similarly,
regardless of socioeconomic status. Age: Bereavement appears to
be somewhat more stressful for younger individuals than it is for
older individuals, with the exception of elderly people.
The disparity between how older individuals are affected and how
elderly people are affected may be because the stress experienced
by elderly people is related to preexisting health problems.
Gender: There is some evidence that men, especially widowers,
have more bereavement-related health problems than women,
especially when dealing specifically with the loss of a
spouse. Although both men and women are deeply affected by
the loss of close family members and friends, the death of a
child may be more difficult for mothers than for fathers. Women
may also recognize the effects of bereavement more readily than
men, and men and women may cope differently.
Individual characteristics
Overall, individuals who are
defined as "neurotic" have been shown to have more health
problems. Low internal locus of control is generally associated
with more depression. This is not specific for bereavement. On
the other hand, high internal locus of control does not act as a
buffer for bereavement-related distress. Anecdotal evidence
suggests that a belief in life after death may be protective.
However, when this was examined in a study, a protective effect
was not found (Stroebe & Stroebe, 1987). Guilt or self-blame
about the death may contribute to traumatic grief.
Relationship quality
Relationship quality may affect men
and women differently when it comes to difficulty with
bereavement. A good marriage may be associated with more
bereavement-related problems in women, while the opposite may be
true for men. In general, data does not support clinical lore
that implies that bereavement problems occur because of
ambivalence or problems in a relationship. It is very clear that
in some instances an especially positive relationship may be
associated with very difficult bereavement reactions.
Circumstances of the death
Not surprisingly, sudden death
is associated with more symptoms of bereavement difficulty in the
first 6 months after the loss. In some studies this difference
was not present in later interviews, while in other studies it
was. A low score on a measure of internal locus of control
signified a greater likelihood for difficulty for younger
bereaved spouses. In some studies, there is evidence of
continuing distress from the loss for many years following a
sudden, violent loss. Experiencing multiple losses or witnessing
the death (especially a factor for children who witness a death)
has been found to correlate with levels of grief intensity.
Feelings of helplessness and powerlessness, survivor guilt,
threat to one's own life, confrontation with the massive and
shocking deaths and mutilations of others, and a violation of
one's assumptive world of safety and meaning are traumatic
factors that may impact a person's ability to resolve grief.
It is clear that many of those bereaved by the WTC disaster may
experience treatable psychiatric difficulties for a long period
of time. It is important for professionals to be vigilant about
this possibility.
Social context
Both perceived and received social support
are related to lower symptoms of depression in the general
population, but there does not appear to be a specific
relationship between social support and bereavement outcome.
However, it is important to note that bereaved individuals often
perceive that others lack empathy and that others are hostile
about the bereaved's continued symptoms. This perception is
likely related to a poorer outcome but has not been specifically
studied. In general, however, social support and positive family
functioning, along with the opportunity to express grief, may
help to mitigate the negative effects of bereavement.
Treatment of bereaved individuals
Grief support groups and grief counseling are widespread and
undoubtedly highly variable. Little information is available
related to support group and counseling outcome. There is
specific controversy regarding the importance of confronting the
death (also called "grief work") in the early phase of grief. In
one study (Stroebe), investigators developed a measure to assess
the extent to which individuals confronted or avoided their loss
and used scores on this instrument to predict outcomes at later
times. They found that low scores for widows did not influence
outcome, but low scores for widowers predicted poorer outcome.
There is some evidence that the occurrence of symptoms of major
depression in the first month following the death predicts a
worse course later, especially for suicidally bereaved
individuals (e.g., Jordan, 2001).
It goes without saying that the loss of a close relationship
permanently affects the bereaved person. It is not reasonable to
think that one can recover from such a loss or resolve the loss.
Such a loss is permanent and has permanent effects on the
bereaved. Still, it is possible and important that the bereaved
person will eventually have comforting memories of the deceased
and feel interested in and able to engage in life. Weiss (1993)
provides a list of reasonable expectations we can have for the
bereaved. A person who has lost someone should eventually
have (1) the ability to give energy to everyday life, (2)
psychological comfort, or freedom from pain and distress, (3) the
ability to experience satisfaction and gratification in life, (4)
hopefulness for the future, and (5) the ability to function
adequately in a range of social roles. How can a professional
assist the bereaved in achieving these goals?
The role of a professional in the early phase of disaster
bereavement
There is little data on the effectiveness of early
intervention for grief. However, it is clear that early
intervention is a good idea following a disaster, provided a
skilled, empathic clinician administers the intervention.
Although data suggest that even after sudden, violent death, most
people eventually grieve successfully, the initial process can
take a long time. Many people consider grief to be a personal
experience and so do not turn to mental-health professionals for
help with grief. However, when a loss is sudden and violent, the
intensity of emotions can be frightening and the need for support
and outside intervention greater. In response, the professional
needs to engage in a skilled, supportive intervention. Useful
components of such an intervention include:
Providing information about grief and its symptoms, course,
and complications
Evaluating the nature of the individual's distress
Helping to identify and solve practical problems
Providing strategies for management of intense feelings
Helping the person think about the death in a way that leads
to emotional resolution
Affect-evoking interventions must be used with care and expert
skill and be balanced with containing and soothing strategies.
During the early phase of bereavement, it may be very useful to
provide information and strategies for thinking about the death.
It is best if the professional provides some follow-up and
remains available for consultation and support, should this be
needed.
Prigerson and Jacobs (2001) provide a list of "do's" and
"don'ts" for how physicians might interact with family
members following a patient's death. These may also be
useful to consider. The authors recommend:
Direct expression of sympathy
Acknowledgement that the clinician does not know exactly what
the bereaved person is going through
Talking about the deceased, including saying his or her
name
Eliciting questions about the circumstances of the death
Asking questions about feelings and about how the death has
affected the person
The authors also provide a useful list of cautions about
things that are
NOT HELPFUL, including:
A casual or passive attitude (e.g., Do not merely say, "Call
me if you want to talk," or ask "How are you?")
Statements that the death is in any way for the best or
acceptable (e.g., "He/she is in a better place," or "It's
God's will.")
An assumption that the bereaved is strong and will/should get
through this
Any kind of avoidance of discussion of the death or the person
who died
Even given its private nature, variable course, and usual
resolution, there are circumstances in which grief can be intense
and prolonged, hindering reengagement in daily activities. When
this occurs, a focused intervention may be needed. There is wide
acknowledgment that bereavement can be prolonged and that it can
lead to other mental-health problems, especially depression and
anxiety. Therefore, professional intervention may be especially
important if the bereaved exhibits the risk factors discussed
above.
Treatment strategies for complications of bereavement
Treatment should target the symptoms experienced by the
patient. It is now very clear that bereaved individuals who have
Major Depressive Disorder (MDD) respond to antidepressant
medication and/or psychotherapy similarly to those who are not
bereaved. A very interesting recent study suggests that treatment
of MDD as early as a month after the death may be extremely
helpful and prevent later symptoms. Similarly, for those who meet
criteria for PTSD, it makes sense to provide treatment similar to
that used with other PTSD patients. However, the most common
postbereavement problems center around traumatic grief reactions,
and unfortunately, few treatments have been developed or tested
for symptoms of Traumatic Grief. Studies of early intervention
for grief document some reduction in grief symptoms, with support
groups showing efficacy equal to that of active psychotherapy. An
early study of a behavioral therapy called "guided mourning" also
appeared to have beneficial effects, although grief outcome was
not measured. A specific "Traumatic Grief Treatment" (TGT) is
currently undergoing randomized controlled testing.
In a pilot study, TGT had a large
effect size, even taking into consideration individuals who did
not complete the full course of the treatment (Shear, 2001).
Components of this treatment include:
Providing information about bereavement and grief to bereaved
individuals and their families
The bereaved describing the deceased and relating the history
of the relationship with the deceased
Relating the story of the death and its aftermath
Careful assessment of current grief levels, target grief
levels, and components of grief (i.e., cognitive, behavioral, and
somatic)
Reviewing the bereaved's personal goals and determining
how the bereaved person will know when these goals have been
met
Carefully managed imaginal exposure to the death and related
events
In vivo exposure to situations that are avoided and/or
response prevention for situations of preoccupation
Focusing on positive memories of the deceased
Therapists should undertake imaginal exposure only if they are
familiar with this technique and with emotion control techniques.
The remainder of the treatment may be of help alone, but it has
not been tested. It is also important to evaluate the bereaved
person's social support system and encourage engagement with
existing supportive people. To date, no treatment has been proven
effective in the early stages of bereavement, and there is some
indication that for some people formal grief counseling can do
more harm than good. In light of this, caution may be
indicated.
Guidelines for early treatment in the acute phase of Traumatic
Grief include:
Allowing the bereaved person to talk about the nature and
circumstances of their loss according to their own readiness
(without probing)
Educating about the course of bereavement and what to
expect
Assessing for possible troubling symptoms like an unusual
intensity of grief reactions or intrusive thoughts
Encouraging, as much as possible without intruding, the use of
social support and the broadening of activities
Encouraging positive memories and a feeling of connection to
the deceased, which may help supplant traumatic memories
Pharmacotherapy may also be helpful for individuals suffering
from Traumatic Grief. However, little has been done to test
pharmacotherapy. As with depression and PTSD, it appears that
serotonin active medications have some beneficial effect
(Zygmont, 1998). Given the available information, it is important
that clinicians learn to administer the techniques that appear to
be efficacious.